After 3 hours in the supine position, an older patient tells the nurse that he or she is stiff and too uncomfortable to move. Which is the best nursing intervention to maintain skin integrity?
a. Find an assistant to help move the patient to lateral position now.
b. Express concern about the discomfort and promise to come back.
c. Assess the patient's need for pain medica-tion before repositioning.
d. Explain how important repositioning is for preventing pneumonia.
C
Lying motionless is common behavior for patients in pain. This older patient is likely to have thin, fragile skin and by not moving for 3 hours, has an increased risk of skin breakdown from tissue hypoxia. The nurse assesses the patient's pain and determines a need for pain medication before attempting to reposition him or her. To preserve skin integrity and promote patient comfort, the nurse moves the patient to another position to facilitate the flow of oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene if necessary. Ex-pressing concern about the pain does nothing to assess or treat the discomfort. Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.
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